Pesticide Use Environmental Assessment Form

Applicant/Operator Name Organization/Farm Date of Application Location of Pesticide Use

Pesticide Name (Product/Active Ingredient) Purpose of Use Application Method Spray Soil Drench Seed Treatment Other Amount and Concentration (Specify units)

Target Pest/Species Potential Non-Target Impact (People, Animals, Plants)

Proximity to Water Sources Weather Conditions at Application Size of Treated Area (Specify units)

Mitigation Measures/Precautions Additional Comments or Notes